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ORIGINAL PAPER
Oral tongue cancer patients show a better overall survivalthan base of tongue cancer patients
Liuyang Zhang • Xuan Zhou • Xiaofeng Yao •
Yansheng Wu • Qiang Zhang • Lun Zhang
Received: 13 October 2011 / Accepted: 21 November 2011 / Published online: 3 December 2011
� Springer-Verlag 2011
Abstract
Purpose The purpose of this study was to compare the
prognosis of oral tongue cancer patients and base of tongue
cancer patients.
Methods One hundred oral tongue cancer patients (group
A) were matched with 50 base of tongue cancer patients
(group B) for gender, age, T-stage, and tumor differentia-
tion in this study. Survival rate was performed using the
Kaplan–Meier analysis, and multivariate analysis was
conducted using the Logistic regression model.
Results There was difference in the survival rate between
the two groups. Three- and 5-year OS (overall survival) of
the two groups were 65.0, 51.0% for group A and 40.0,
28.0% for group B, respectively. For the two groups, 3- and
5-year DSS (disease-specific survival) were 61.0, 46.0%
for group A and 38.0, 26.0% for group B, respectively.
Multivariate analysis showed that recurrence (P = 0.019)
and regional lymph node metastasis (P = 0.043) were
significant between the group A and group B patients.
Conclusion The oral tongue cancer patients had a better
prognosis than base of tongue cancer patients. The differ-
ence in prognosis between the oral tongue cancer and the
base of tongue cancer patients in this study was closely
associated with the recurrence and regional lymph node
metastasis. We conclude that the individual treatment
should be used for base of tongue cancer patients.
Keywords Squamous cell carcinoma � Base of tongue �Oral tongue � Disease characteristics � Prognostic factors
Introduction
Squamous cell carcinoma (SCC) of tongue is one of the most
common oral cancer in western countries (Moore et al. 2000).
The tongue is a complex organ and can be divided into two
portions: the oral tongue cancer which consists of dorsal sur-
face, lateral and ventral surface/anterior two-thirds; the base of
tongue cancer is defined as the tissue posterior to the circum-
vallate papillae. Although the methodology in the treatment of
SCC tongue has been well developed, the 5-year survival rates
of patients in the worldwide have remained relatively constant
since the early 1970s. According to the population-based
cancer registries data, 5-year survival rate about the oral ton-
gue cancer is around 53%, compared with 33–40% for the base
of tongue cancer (Lam et al. 2006; Zhen et al. 2004). However,
the two studies were carried out in different institutions and no
comparison can be made. It is unclear whether there is a dif-
ference in prognosis between the oral tongue cancer and the
base of tongue cancer patients. Hence, we decided to embark
on a retrospective investigation to analyze the characteristics
and results of patients with tongue cancer in our local patient
population in Chinese with a subset analysis to compare oral
tongue cancer with the base of tongue cancer patients.
Materials and methods
Patient selection
All patients with tongue SCC who received primary treat-
ment in the Tianjin Medical University Cancer Institute and
L. Zhang � X. Zhou � X. Yao � Y. Wu � Q. Zhang �L. Zhang (&)
The First Department of Head and Neck, Key Laboratory
of Cancer Prevention and Therapy, Tianjin Medical University
Cancer Institute and Hospital, Huanhuxi Road, Tiyuanbei,
Hexi District, Tianjin 300060, China
e-mail: [email protected]
123
J Cancer Res Clin Oncol (2012) 138:341–346
DOI 10.1007/s00432-011-1105-y
Hospital between January 1995 and December 2004 were
included in this retrospective analysis. Patients’ character-
istics and outcomes were analyzed separately according to
the sub-site: (1) group A – the oral tongue cancer patients, (2)
group B – the base of tongue cancer patients. One hundred
oral tongue cancer patients were matched with fifty base of
tongue cancer patients. Matching variables were gender, age
at diagnosis, T-stage, and tumor differentiation.
Inclusion and exclusion criteria: Inclusion criteria for the
study were: (1) All patients had a histopathological diagnosis
of SCC; (2) availability of accurate TNM staging; (3) avail-
ability of well-documented clinical information; (4) avail-
ability of follow-up clinical information for more than
5 years; (5) curative intent. Exclusion criteria for the study
were: (1) presence of distant metastatic at the time of initial
diagnosis and treatment; (2) patients undergone tongue sur-
gery at a different institution; (3) Two patients were subse-
quently excluded because they refused treatment; (4) four
patients were lost to follow-up. The staging of the two groups
was adopted by the American Joint Committee on Cancer
(AJCC) system. Therapeutic in this report reflected only the
initial treatment for patients about the two groups. Invasion of
surrounding tissues which were confirmed by surgical-path-
ologic results included tongue muscles, floor of mouth, ton-
silla, hypopharyngeal nerve, and so on.
Calculating survival time
Overall survival was calculated from the date of diagnosis
to the date of death due to all causes. Disease-specific
survival was measured as the percentage of patients alive
more than 5 years divided by the total number of patients
who died of the tumor. The last follow-up date and current
status of the patient were recorded.
Statistical analysis
The Chi-square test was used to compare the tongue cancer
characteristics between the two groups for qualitative data. OS
and DSS were calculated using Kaplan–Meier method. And
Log-Rank was used to compare curves between groups.
Univariate and Multivariate analysis were performed using
the Pearson Chi-square test and a binary logistic regression
test, respectively. P \ 0.05 were considered statistically sig-
nificant. Statistical analysis was performed using SPSS18.0
for Windows.
Results
Basic characteristics of study groups
The age of the group A ranged from 28 to 79 years (mean
54.58 years; median 54.50 years). The age of matched
group B ranged from 21 to 73 years (mean 53.00 years;
median 53.00 years).
We analyzed the basic characteristics of our study two
groups, including gender, age, T-stage, tumor differentia-
tion, tumor site, therapeutic modality, invasion of sur-
rounding tissues, TNM stage, recurrence, regional lymph
node metastasis, margin of resection, and tumor across the
midline (Tables 1, 2). The first four characteristics (espe-
cially the tumor site which was identical in each matched
group) were the criteria used for matching the two groups
(Table 1).
Univariate and multivariate analysis of the clinical
factors between the two groups
In univariate analysis, there were significant differences in
the TNM stage (P = 0.004), recurrence (P = 0.000),
regional lymph node metastasis (P = 0.001), and tumor
across the midline (P = 0.008) between the two groups
(Table 2). However, there were no significant differences
between the two groups in terms of tumor size
(P = 0.052), therapeutic modality (P = 0.196), invasion
of surrounding tissues (P = 0.079), and margin of resec-
tion (P = 0.783) in univariate analysis (Table 2). Multi-
variate analysis showed that recurrence (P = 0.019) and
regional lymph node metastasis (P = 0.043) were signifi-
cant between the group A and group B patients (Table 3).
The survival rate
For the two groups, 3- and 5-year OS were 65.0, 51.0% for
group A and 40.0, 28.0% for group B, respectively (Fig 1).
Table 1 The two groups of criteria for matching
Variable Group A
(n = 100) (%)
Group B
(n = 50) (%)
v2 P value
Gender 0.000 1.000
Male 62 (62) 31 (62)
Female 38 (38) 19 (38)
Age 0.000 1.000
B45 20 (20) 10 (20)
[45 80 (80) 40 (80)
T-stage 0.000 1.000
T1 26 (26.0) 13 (26.0)
T2 40 (40.0) 20 (40.0)
T3 24 (24.0) 12 (24.0)
T4 10 (10.0) 5 (10.0)
Tumor
differentiation
0.000 1.000
Well 80 (80) 40 (80)
Moderate or
poor
20 (20) 10 (20)
342 J Cancer Res Clin Oncol (2012) 138:341–346
123
The difference between the two groups was significant
(P = 0.001, Fig 1). For the two groups, 3- and 5-year DSS
were 61.0, 46.0% for group A and 38.0, 26.0% for group B,
respectively (Fig 2). The difference between the two
groups was significant (P = 0.000, Fig 2).
Discussion
Disease characteristics
Oral cavity cancer is diagnosed in over 263,900 new cases
and 128,000 deaths in 2008 worldwide (Jemal et al. 2011).
SCC accounts for majority of oral tongue and base of
tongue cancers and most common in males and in older
patients. Several approaches can be used to the oral and
base of tongue cancer, but suitable management is still
controversial. In our study, 20% patients were aged 45 or
under and 62% were males, respectively (Table 1). Other
studies reported 10–30% of patients younger than 40 or
45 years (Gorsky et al. 2004; Park et al. 2010). There is
much evidence suggesting that head and neck cancers,
particularly SCC oral tongue cancer, are increasing in
young patients. However, the factors that account for oral
cancer in young patients remain unclear. The base of SCC
tongue is a challenge for many surgeons. Several approa-
ches can be used to the base of tongue cancer, but suitable
management is still controversial. Surgical management
with adjuvant radiotherapy in the reported studies was
associated with a high rate of survival rate but with some
impairment of speech, mastication, swallow, and sensation
function. As to the clinic factors closely related to the
different prognosis between the two groups patients yet to
be further studied?
Survival
Oral cancers are connected with a relatively high mortality
rate particularly in the developing countries (Parkin et al.
2005; Petersen 2009). Approximately 17% of these are
actually located in the base of tongue. As for OS, there was
discrepancy between oral tongue cancer and base of tongue
cancer in the literature. Hammarstedt et al. (2011) found that
for patients with base of tongue cancer have an overall
improved survival, but a very modest improvement about
survival for patients of tongue cancer during the last decades
Table 2 The characteristics of
two groups
S surgery, RT radiotherapy,
CT chemotherapy
Variable Group A (n = 100) (%) Group B (n = 50) (%) v2 P value
Tumor size 3.768 0.052
B2.0 cm 40 (40.0) 12 (24.0)
[2.0 cm 60 (60.0) 38 (76.0)
Therapeutic modality 4.694 0.196
S 9 (9.0) 10 (20.0)
S ? RT 52 (52.0) 23 (46.0)
S ? CT 17 (17.0) 10 (20.0)
S ? RT ? CT 22 (22.0) 7 (14.0)
Invasion of surrounding tissues 3.079 0.079
Yes 53 (53.0) 34 (68.0)
No 47 (47.0) 16 (32.0)
TNM stage 8.335 0.004
I–II 59 (59.0) 17 (34.0)
III–IV 41 (41.0) 33 (66.0)
Recurrence 12.315 0.000
Yes 32 (32.0) 31 (62.0)
No 68 (68.0) 19 (38.0)
Regional lymph node metastasis 11.618 0.001
Yes 31 (31.0) 30 (60.0)
No 69 (69.0) 20 (40.0)
Margin of resection 0.076 0.783
Negative 78 (78.0) 38 (76.0)
Positive 22 (22.0) 12 (24.0)
Across the midline 6.936 0.008
Yes 11 (11.0) 14 (28.0)
No 89 (89.0) 36 (72.0)
J Cancer Res Clin Oncol (2012) 138:341–346 343
123
in Sweden. Rusthoven et al. (2008) reported the 5-year OS
rate of the oral tongue cancer patients from the Surveillance,
Epidemiology, and End Results (SEER) database was
60.9%. In their study, the oral tongue cancer patients were
stage I and II (T1-T2N0M0) between 1988 and 2004. If they
included the stage III and IV patients in their study, the
5-year OS rate would be far lower than 60.9%. Whereas
Shim et al. (2010) reported that the 5-year OS of 86 patients
treated with surgery alone or combined postoperative
radiotherapy was 80.2%. However, 5-year survival rates
about the base of tongue cancer have ranged from 42.4 to
87%. Sessions et al. (2003) reviewed 5-year OS rate of 42.4%
for all stages in 262 patients and that the 5-year DSS was
49.6% for 224 patients; the difference between 5-year OS
and DSS was not significant (P = 0.113). Harrison et al.
(1998) reported that 5-year OS of 68 patients using primary
radiotherapy with or without neck dissection was 87%. The
reason of discrepancies among researches is unknown and
can be hypothesized that patients’ characteristics, treatment
modality, TNM stage, statistical techniques, and number of
patients enrolled may each have played a vital role in
explaining these different outcomes.
The survival or outcome of tongue SCC was closed
relation with T-stage (Sessions et al. 2003) and age of
diagnosis (Ho et al. 2008). In our study, we matched the
T-stage, tumor differentiation, and age of diagnosis to
compare the differences between oral tongue cancer and
base of tongue cancer patients. The 5-year OS of the cur-
rent report in the two groups were 51 and 28.0%, respec-
tively. Multivariate analysis indicated that recurrence
(P = 0.019) and regional lymph node metastasis
(P = 0.043) were connected with lower OS in the group B.
Our results agreed with a previous study (Lam et al. 2007)
and demonstrated that the oral tongue cancer had a better
prognosis than base of tongue cancer patients when the
whole group was analyzed. Recurrence and regional lymph
node metastasis were the significant prognostic factors for
base of tongue cancer patients. Once the patients were
founded lymphatic metastases, the survival rate of tongue
SCC would be decreased by 50%. Most patients with SCC
base of tongue were found advanced-stage, defined by
either recurrence or regional metastasis. Other studies have
reported similar models of presentation. Mendenhall et al.
(2000) reported that 71% of their patients revealed with
stage IV disease and Kraus et al. (1993) reported that 81%
of the patients had either stage III or IV disease. In the
present study, thirty-three patients (66%) were advanced-
stage (III–IV) in the group B. Base of tongue cancer is
difficult to operate, because of its deep location and a large
volume on the oropharynx. When patients occurred sig-
nificant symptoms, the tumor almost invaded surrounding
tissues and occurred metastasis of lymph node.
Table 3 Cox regression analysis of the two groups
Variable B SE Wald P value 95% CI
TNM stage -1.015 0.868 1.368 0.242 0.066–1.986
Recurrence 0.935 0.400 5.464 0.019 1.163–5.584
Regional lymph node metastasis 1.616 0.798 4.096 0.043 1.052–24.053
Across the midline 1.075 0.570 3.562 0.059 0.959–8.953
SE standard error, CI confidence interval
Fig. 1 Overall survival for the two groups (P = 0.001)
Fig. 2 Disease-specific survival for two groups (P = 0.000)
344 J Cancer Res Clin Oncol (2012) 138:341–346
123
Over the last decade, although the incidence of HNSCC
has been falling in all subsites, the oropharynx (specifically
the base of tongue), where UK (Reddy et al. 2010) and
Sweden (Attner et al. 2010) rates have been increasing. The
incidence rates of HPV (Humanes Papillomavirus) infec-
tions for oral cancer sites (such as the oropharynx, tonsil,
and base of the tongue) are increasing in young adults in
the United States and in some countries in Europe. For
oropharyngeal carcinoma patients, HPV-positive respond
considerably better than HPV-negative in radiochemo-
therapy (Lill et al. 2011) and in cetuximab combined with
chemotherapy (Kies et al. 2010).
Recently, molecular targeted therapies for patients with
HNSCC are opening new options. The cetuximab, a
monoclonal antibody to EGFR, has been reported
improved survival for patients with advanced HNSCC
(Kies et al. 2010; Suntharalingam et al. 2011). In a recent
phase II trial, adding cetuximab to cisplatin-based che-
motherapy for the locally advanced head and neck cancer
significantly improved the proportion of complete response
(CR), and the toxic effects are similar to those expected by
radiochemotherapy (Merlano et al. 2011). Bonner et al.
(2010) reported the 5-year OS benefit from the cetuximab-
plus-radiotherapy group (45.6%) compared with the
radiotherapy-alone group (36.4%) for locoregionally
advanced HNSCC. Although cetuximab combined with
other treatment really improve the local control and OS for
SCCHN patients, it increases additional adverse effects
such as skin rash, dermatitis (Selzer et al. 2011), and
mucosal toxicity. Birnbaum et al. (2010) demonstrated that
cetuximab in combination with paclitaxel, carboplatin, and
intensity modulated radiation therapy increases dermato-
logic toxicity but does not increase mucosal toxicity as
compared with none cetuximab for patients with head and
neck cancer. Although current clinical trials suggest that it
is difficult to control tumors and increase survival time just
inhibition of one signal pathway, HNSCC patients (espe-
cially HPV-positive base of tongue cancer patients) could
improve quality-of-life and extended survival for the
treatment included cetuximab.
Conclusion
In conclusion, the present study is to compare the prognosis
of matched oral tongue cancer and base of tongue cancer
patients in China. We have demonstrated that oral tongue
cancer patients had a better 3- and 5-year survival rate in
the whole group. We propose that the difference in prog-
nosis between the oral tongue cancer and the base of ton-
gue cancer patients in this study was closely associated
with the recurrence and regional lymph node metastasis.
We conclude that the individual treatment should be used
for base of tongue cancer patients.
Acknowledgments The authors thank Jon Teng for help with
modifying the paper.
Conflict of interest None.
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